Ra

Epistemic status: very speculative. This is mythmaking: you’ve been warned.

Ra is the Sun God

The Egyptian god Ra was a symbol of divine kingship, all-powerful and all-seeing.  He’s a good metaphor for a certain kind of psychological phenomenon that involves thought distortions around authority and legitimacy.  A new demon, if you will, in the grimoire that includes Moloch and Azathoth.

The idea of a malign Establishment is somewhat convergent:

The Establishment (attributed to Henry Fairlie in 1950’s Britain, talking about an informal social network of power among prominent, well-connected people)

The Man (e.g. Yippies, Burning Man)

The Combine (Ken Kesey)

Moloch (Allen Ginsberg)

The Beige Dictatorship (Charles Stross)

The Cathedral (Mencius Moldbug)

The Mandarins (Megan McArdle)

Not all of these ideas are coterminous with Ra, or identical to each other.

What they have in common is that the Establishment is primarily an upper-class phenomenon, that it is more about social and moral legitimacy than mere wealth or raw power, and that it is boringly evil — it produces respectable, normal, right-thinking, mild-mannered people who do things with very bad consequences.

What Ra is not

The usual pitfall when using poetic language to define egregores is making them too broad.  There is not one root of all evil that causes all the ills of the world.

Ra is not simply conformity, simply authoritarianism, or simply power-seeking.  Ra is not the same as “bureaucracy” or “capitalism” or “fallen human nature” or all the myriad reasons why your idealistic goal might fail.  Ra is not “everything that is wrong with people who disagree with me.”

As a social phenomenon, Ra is responsible for some dysfunctions in the democratic modern West; it is not, for instance, what was going on with the Nazis, or with terrorists, or with communist revolutionaries, or with the Confederates in the American Civil War.  Ra is not driving people who want to take over the world for some fanatic goal. It’s more like a dissipating, entropic motion, a process that corrupts institutions.

But it’s not merely the most commonly claimed drivers of institutional decay, like “knowledge problems” or “coordination problems”.  People who participate in those problems are following rational self-interest, but wind up contributing individually to collectively harmful outcomes.  Ra is something more like a psychological mindset, that causes people to actually seek corruption and confusion, and to prefer corruption for its own sake — though, of course, it doesn’t feel quite like that from the inside.

Ra is a specific kind of glitch in intuition, which can roughly be summarized as the drive to idealize vagueness and despise clarity.  I’m going to try to define it by extension, using examples from my and others’ personal experiences.

Ra is about generic superlativity.

You know how universal gods are praised with formulas that call them glorious, mighty, exalted, holy, righteous, and other suchlike adjectives, all of which are perfectly generic and involve no specific characteristics except wonderfulness?  That’s what Ra is all about.

The worship of Ra involves a preference for stockpiling money, accolades, awards, or other resources, beyond what you can meaningfully consume or make practical use of; a felt sense of wanting to attain that abstract radiance of “bestness”.

A featureless, powerful organization, something with a name like “Acme Corp”, whose activities you can’t pin down, is archetypally Ra.  Especially if it’s associated with markers of excellence (e.g. very smart high-achieving employees) or fully general capabilities (eg the most powerful computers in the world). OpenAI has a lot of this quality, as does Google, as did Enron before its collapse, as do top management consulting firms and investment banks and Ivy League schools. Effective Altruism, when it’s just “a movement for generic optimal goodness”, has a lot of this quality.  When an organization seems shiny, full of the best and brightest, and is presumed to be potentially good at everything, it is appealing in a very Ra-flavored way.

In my mind I synaesthetically imagine Ra as radiant white light and smoothness (as in “futuristic” computer graphics, or as in mirror-like glossiness.)

Ra is evident in marketing that is smooth, featureless, full of unspecified potential goodness, “all things to all people,” like Obama’s 2008 campaign.  (Note the logo, with its smooth gradient and radiant white sun.)  Apple’s design is also very Ra.

Ra is about legitimacy.

When someone is willing to work for prestige, but not merely for money or intrinsic interest, they’re being influenced by Ra.  The love of prestige is not only about seeking “status” (as it cashes out to things like high quality of life, admiration, sex), but about trying to be an insider within a prestigious institution.  Not only “people like and respect and desire me” but “this abstract, objective Thing full of goodness has sanctioned me.”  People with money or charisma but no prestige read as sleazy (e.g. gamblers, gurus) while people with status and prestige/insiderness read as legitimate (e.g. the rightful king or official priest or licensed professional.)

Ra involves seeing abstract, impersonal institutions as more legitimate than individuals. For instance, I have the intuition that it is gross and degrading to pay an individual person to clean your house, but less so to hire a maid service, and still less so if a building that belongs to an institution hires a janitor.  Institutions can have authority and legitimacy in a way that humans cannot; humans who serve institutions serve Ra.

Seen through Ra-goggles, giving money to some particular man to spend on the causes he thinks best is weird and disturbing; putting money into a foundation, to exist in perpetuity, is respectable and appropriate.  The impression that it is run collectively, by “the institution” rather than any individual persons, makes it seem more Ra-like, and therefore more appealing.

Ra causes avoidance of challenging regulators and establishment hierarchies in significant excess of the actual legal and reputational costs of doing so.  Not just caution, but a sort of unbounded over-caution that makes you willing to throw huge amounts of value away to reduce already small risks.  Selfishness can motivate caution and even conformity; Ra-worship motivates sacrificing excess value to institutions you view as more legitimate than yourself.

Once, the CEO of a hedge fund and a friend of mine were in a heated argument, and the CEO finally pushed his point home by saying “200 PhDs work for me, so I know what I’m talking about.”  This is argument by legitimacy.  It’s just saying “because my institution has piled up a lot of excellence in one place, I get to talk and you have to shut up.”  It’s not an argument from expertise like “My 200 physics PhD’s agree with my point about physics” would be. It’s not even a direct power claim like “My 200 armed security guards will make you shut up.”  The guards would be a practical threat; the PhD’s really aren’t.  But they would be, to someone who believed that they granted legitimacy, that the accumulation of PhDs proved that the CEO had more right to speak and think.

Ra defends itself with vagueness, confusion, incoherence — and then anger.

“Respectability” turns out to be incoherent quite often — i.e. if you have any consistent model of the world you often have to take extreme or novel positions as a logical conclusion from your assumptions. To Ra, disrespectability is damnation, and thus consistent thought is suspect.

Vagueness, mental fog, “underconfidence”, avoidance, evasion, blanking out, etc. are hallmarks of Ra.  If cornered, a person embodying Ra will abruptly switch from blurry vagueness to anger and nihilism.

I have, in Ra-influenced moods, had the intuition “I don’t know if it’s possible to be a consistent economic agent [i.e. von Neumann-Morgenstern] and still be good.” Consistency implies the potential for disobedience. Consistency means you might not be recruitable or available to arbitrary purposes.  It’s the opposite of malleability.  Ra wants its worshippers to be always available, always malleable; and calls it “wicked” to have resistance to that.

One friend of mine discussed having a conversation about the future of humanity with someone, getting the strong sense that this person was being evasive and switching between viewpoints, and also that underneath the evasiveness there was a negative-utilitarian belief that humanity ought to be annihilated. And she worried that if she pushed too hard on insisting the other person make a coherent argument, that he would double down on the negative utilitarianism and become vindictive about it.  This is prototypical Ra behavior.  Smooth, soft vagueness that, when challenged, collapses into angry nihilism.

One symptom of Ra is being offended or upset when friends and allies are not doing things associated with power and status.  Actual insecurity and anger at the sight of someone doing their own thing, behaving in ways that don’t bring them closer to the center of coolness/shininess/power/etc.

Nastasya Philipovna, in The Idiot, demonstrates this kind of anger; when she meets the man who embodies her moral ideal, instead of reaching out to him as a lover, she is outraged that he’s being shabby and noble and ignoring the “way of the world”, and she actively ruins his life. It’s not that she doesn’t appreciate goodness; it’s that it freaks her out.  People ought not be that good. It disturbs the universe.  Myshkin is missing something — it’s not clear what, because if you look at his words and actions explicitly he seems to be behaving quite sensibly and moderately — but he’s missing some intuition about the “way of the world”, and that enrages everyone around him.

I remember being angry at a coworker, once, for attempting to sell a product to big pharma companies, because he was thinking of them too lightly, not appreciating the awesome majesty of the pharma companies that we were barely worthy to submit our ideas to.  He seemed not to understand the unspoken “way of the world”, and that made me angry.  That was classic Ra thinking on my part.

Ra is involved in the sense of “everyone but me is in on the joke, there is a Thing that I don’t understand myself but is the most important Thing, and I must approximate or imitate or cargo-cult the Thing, and anybody who doesn’t is bad.”  E.g. having the intuition that the power to make successful companies lies in things like “complex sales”, without understanding how complex sales works on a nuts-and-bolts level.  If you just associate complex sales guys with power and success, if you have the feeling that they probably know how to become an insider even if you don’t, then you’re engaging in Ra thinking.

Ra causes persistent brain fog or confusion, especially around economic thinking or cost-benefit analysis or quantitative estimates.  E.g. for a while I had a block around the question “How much would it cost to outfit a biology lab?” and thought that this was literally impossible for me to discover the answer to because the information would only be available to properly credentialed biologists or pharma company employees.  I had a weird aversion to seeking information or thinking directly about the problem.  Another time, I had a block around answering the question “How many lives would be saved if all men got HPV vaccines?” because it was epidemiology and people were talking about publishing the results in a journal and I felt unworthy as a non-academic to submit journal articles, so I procrastinated and didn’t even try to do Fermi estimates on the question.

Ra tends to cause confusion and brain fog around modeling preferences, particularly two or more independent agents trying to negotiate mutually beneficial solutions.  When Ra is active, you’ll see a persistent disposition, in otherwise intelligent people, to misunderstand trade or negotiation scenarios as dominance/submission scenarios.

Ra may cause blurriness around objectives. In Drucker’s Management, the purpose of a business (or nonprofit or government agency) is explicitly not to maximize profits or shareholder value, or to produce the best widgets or save the most lives, but to fulfill its function.   But what does that even mean?  It means something like the preservation of the organization — but it’s not specific.

There’s a disinclination to get specific about numbers or negotiations or goals or arguments.  And then an angry sense that people who do get specific are “doing it wrong” or “bad people” and deserve harshness.  An intuition that the really important things in life, the true “ways of the world”, are hidden or mysterious, always unspoken, and must be respected.

Ra hates communication and introspection.

Ra causes a disinclination to express oneself. An impression that a person who is unknown or mysterious is more attractive or favorably received than a person who is an “open book.”  A tendency to prefer private and off-the-record communications. There are many non-Ra reasons for secrecy, privacy, or reservedness (e.g. spies, shy people) — the core Ra quality is not merely the concealment but the idealization of the invisible, an intuition that people who display a smooth surface to the world are better.

Glamour is a related idea (see Virginia Postrel), in particular the glamour of “mystery and illusion.”  Glamorous things or people are idealized precisely because the details are airbrushed out.

There’s also a preference not to engage with people authentically — i.e. being more comfortable asking someone for a pre-packaged response (like “give me money” or “sign this petition”) than asking them to have an open-ended conversation with you.

Ra promotes the idea that optimal politeness conveys as little information as possible. That you should actively try to hide preferences (because if you shared them, you’d inconvenience others by pressuring them to satisfy your preferences).  That all compliments are empty pleasantries.  There’s an interpretation of “politeness” that’s anti-cooperative, that avoids probing for opportunities for genuine mutual benefit or connection and just wants to make the mutual defection process go as smoothly as possible.  Ra prefers this, because it’s less revealing, commits you less, doesn’t pin you down, allows you to keep all your options open and devote everything to the pursuit of Ra.

Ra is involved in intuitions about silence or absence being ideal.  A blank sheet of paper is more beautiful than any art you can put on it, because the art is potentially flawed, while blankness is flawless.  Blankness leaves all the options open. See also The Whiteness of the Whale.

People who write a lot, or enjoy discussions, or spend a lot of time on introspective “inner work”, tend to be less Ra-oriented.  Blogging is very anti-Ra.  Having opinions and making essay-style arguments, for all the flaws of that medium, does promote some degree of coherence and specificity, and promotes people sharing their inner lives.  Having a coherent, specific, shareable inner life means you’re less malleable, less blank, and Ra insists that people’s inner lives be completely malleable and blank.

I’ve had my writing criticized because “when you give your opinion, it sounds like you think you’re smart”.  And I’ve spent a lot of time feeling ashamed of “thinking out loud” in public, because it tarnishes the glossy facade that it’s easy to feel obligated to put up.  I’ve also had my more mainstream, Ivy League friends express surprise that I cared at all or made the slightest effort for friends in trouble.  Being committed or involved in people’s lives is also messy and doesn’t permit the preservation of a flawless impression.  Expressing yourself, thinking speculatively, and relating to people are shameful to the Ra-worshipping mindset, because all mental and emotional resources must be channeled into the quest for prestige.

Gruad Grayface, in the Illuminatus! Trilogy, is one of many figures representing “the Man” or malign technocratic authority, and he is accused of setting people against each other, making them unable to empathize across demographic lines (men and women, black and white), because if they communicated with each other they would realize that they were natural allies and none of them benefited from Gruad’s tyrannical rule.

There’s a persistent theme in the 60’s counterculture ethos that if people just communicated authentically, it would make a big difference to the world. And while this sounds like a platitude, I think it might be an important truth about the nature of Ra. See “The Sound of Silence.”  See Leary’s exhortation to “find the others.”  See the dystopia of perfect conformity that is Camazotz, which is vanquished by human flaws and by the love of specific people. Understanding that everyone has an inner life and nobody is smooth and blank is the antithesis of Ra.

Ra is fake Horus.

Originally, the Egyptian falcon-god Horus was the god representing the Pharaoh’s sovereignty.  The notion of Horus as the pharaoh seems to have been superseded by the concept of the Pharaoh as the son of Ra during the Fifth Dynasty.

Horus was supposed to be literally the Pharaoh; that is, there’s some actual dude in charge, a god-king.  Ra, by contrast, is “father of the Pharaoh”, the un-look-at-able “power behind the throne.”  Instead of sovereignty that rests in an individual, Ra represents the abstract supreme to which the king is subordinate.

If Horus, the far-sighted, kingly bird, represents “clear brightness” and “being the rightful and just ruler”, then Ra is a sort of fake version of these qualities.  Instead of the light that distinguishes, it’s the light too bright to look at.  Instead of clear brightness, it’s smooth brightness.

Instead of objectivity, excellence, justice, all the “daylight” virtues associated with Horus (what you might also call Apollonian virtues), Ra represents something that’s also shiny and authoritative and has the aesthetic of the daylight virtues, but in an unreal form.

Instead of science, Ra chooses scientism.  Instead of systematization and explicit legibility, Ra chooses an impression of abstract generality which, upon inspection, turns out to be zillions of ad hoc special cases.  Instead of impartial justice, Ra chooses a policy of signaling propriety and eliteness and lack of conflicts of interest. Instead of excellence pointed at a goal, Ra chooses virtuosity kept as an ornament.

(Auden’s version of Apollo is probably Ra imitating the Apollonian virtues. The leadership-oriented, sunnily pragmatic, technological approach to intellectual affairs is not always phony — it’s just that it’s the first to be corrupted by phonies.)

Horus is not Ra.  Horus likes organization, clarity, intelligence, money, excellence, and power — and these things are genuinely valuable. If you want to accomplish big goals, it is perfectly rational to seek them, because they’re force multipliers.  Pursuit of force multipliers — that is, pursuit of power — is not inherently Ra.  There is nothing Ra-like, for instance, about noticing that software is a fully general force multiplier and trying to invest in or make better software. Ra comes in when you start admiring force multipliers for no specific goal, just because they’re shiny.

Ra is not the disposition to seek power for some goal, but the disposition to approve of power and to divert it into arbitrariness. It is very much NOT Machiavellian; Machiavelli would think it was foolish.

Ra corresponds to a stage in the corruption of organizations.

Thomas W. Lamont is an excellent example of Ra.  He was a banker at JP Morgan in the 1930’s who was famously gifted at communication, very much one of the club (Harvard and Exeter), somewhat “idealistic” but in a very vague sense that mostly amounted to rationalizing whatever power structure was nearby.  He ended up making major loans to militarist Japan and Mussolini, and was a major apologist for them right up until the situation became intolerably obvious; at which point without any apparent sense of shame he gave up on them, after making sure his friends were taken care of (e.g. negotiating a Morgan banker’s release from Italian imprisonment).

Lamont’s communication to the Japanese and later to Mussolini was all “I know you mean well but it’s getting harder to defend you, here’s some suggestions for how to clear up the obvious misunderstanding.”  He’s not a cynical power-seeker in these letters; he’s genuinely righteously indignant at people doubting his “ideals.”  There’s no master plan to gain power for himself or for an ideology he supports. He just seems to think “clearly the people gaining power must be good!”

The Lamonts of the world generally show up after the founding generation, after people like J. Pierpont Morgan himself, who was a genuine innovator who developed “modernization” techniques to make the businesses he took over profitable.  Vague objectives are only possible once institutions that steadily produce value have already been set in motion.  You see Ra-like figures at around the peak of an institution’s flourishing, when it’s begun to be possible to capture value without producing any, but before the decline is so severe that overtly exploitative behavior is socially acceptable.  Ra has a quality that’s triumphalist and slightly disconnected from reality — “Our institution is so powerful and wonderful that its proper sphere is the whole world!  And its job is to perpetuate its own flourishing!”

Ra is easy to overcome

As forces in the human psyche go, Ra is a pretty mild one. It’s not a powerful biological drive like aggression, or a difficult-to-treat problem like depression, or a highly optimized energy-saving structure like the standard cognitive biases.

Ra is hard to pin down, but vulnerable to open communication and introspection.  If you can talk and think about what you want, or how you feel, or why you believe what you do, and you don’t dodge the question, Ra will dissolve like mist. The illusion of smooth impersonal perfection doesn’t survive long after you get to know particular human beings. The subjective impression of something being like a vague glowy ball of positive affect doesn’t survive explicit discussion or analysis.  The sensation of total unknowability doesn’t survive the attempt to actually find things out.

It’s so faint and wispy that many people might say “Ra doesn’t have any part in my life!”  And you might be right.  Or it might be hidden in hard-to-find places, in certain questions you don’t ask and tasks you delay starting. It’s very, very rare for people to say “yes, I totally experience these things.”  But if you notice them, and are aware that they don’t make sense, then the fog yields to sunlight.

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Cross-Sex Hormone Therapy: Female Hormones

Scope Of Report

For the purposes of this report, we’re looking at cross-gender hormone therapy for assigned-male-at-birth individuals — that is, estrogen and anti-androgens, as they are generally taken by transgender women and others seeking to feminize their bodies.  I’ll look into the evidence for the medical and psychological risks and benefits of these drugs.

Bottom Lines

  • hormone therapy consisting of estrogen and an anti-androgen is mostly safe: the biggest risk is cardiovascular problems
  • the anti-androgen cyproterone acetate is riskier than other anti-androgens: it’s associated with venous thromboembolism, hyperprolactinemia, and possibly impaired mood and cognitive ability. It can be substituted with spironolactone, or in some cases with no anti-androgen at all.
  • hormone therapy for trans women improves mood and agreeableness, reduces gender dysphoria, and has some feminizing effects on appearance
  • hormone therapy does change brain size but doesn’t impair cognitive performance
  • trying to get an “androgynous” outcome by taking anti-androgens without estrogen is a bad idea and does cause cognitive impairment and depression.

Risks of Hormone Therapy: Venous Thromboembolism

The most common risk of hormone therapy in trans women is venous thromboembolism. This is when a blood clot in a vein breaks loose and travels in the blood; if it reaches the lungs it is called a pulmonary embolism and can be very dangerous. About 5% of people with venous thromboembolisms die.[1]

In the largest study, 1076 individuals, the rate of venous thromboembolism is 1%; smaller studies find 5-6% rates.[2]  Some small studies (162 individuals) suggest that transdermal estrogen has less risk of venous thromboembolism than oral estrogen.

The risk of venous thromboembolism is also elevated in hormonal birth control, which, like hormone therapy, contains female hormones.  Current users of estrogen-containing birth control have about double the yearly risk of venous thromboembolism of female non-users. Birth control containing the progestin cyproterone acetate is associated with 1.88x the venous thromboembolism risk of birth control with other progestins.[3]  This is relevant because cyproterone acetate is also an anti-androgen sometimes used in cross-gender hormone therapy; avoiding cyproterone acetate could reduce the risk of venous thromboembolism.

Risks of Hormone Therapy: Osteoporosis

Estrogen is associated with osteoporosis: 25% of 100 transgender women had osteoporosis after more than 10 years of HRT, whereas transgender men did not.[2]

Risks of Hormone Therapy: Hyperprolactinemia

The anti-androgen cyproterone acetate can cause hyperprolactinemia.

High levels of the hormone prolactin can cause symptoms such as breast discharge, erectile dysfunction and reduced libido, infertility, breast growth, decreased body hair and muscle mass, and headaches. (Not all of these may be undesirable for trans women, of course.)  It is not otherwise dangerous, and can be treated with dopamine agonists such as bromocriptine.

In a total of 1109 trans women across six studies, there were elevated prolactin levels in 19.5%. [5]  Trans women on hormone therapy have much higher rates of migraine than the baseline population: 26% out of 50, as opposed to a baseline rate of 6%.  This may be due to higher prolactin levels.[6] 14/47, or 30% of trans women reported new sources of pain after going on hormones, in particular headaches, breast pain, and musculoskeletal pain.[7] This may also be a result of hyperprolactinemia, or it may be related to other hormonal-balance issues (women generally are more pain-sensitive than men.)

Cyproterone acetate increases prolactin levels; spironolactone does not. (p = 0.0002).[8]  Avoiding cyproterone acetate seems likely to reduce the risk of hyperprolactinemia.

Risks of Hormone Therapy: Infertility

Estrogen therapy usually eliminates the production of sperm.  In 7 out of 10 trans women on estrogen, there was no spermatogenesis.[53] A single male given estrogen had a pronounced drop in sperm motility and density by 4 weeks of estrogen treatment, though it did recover after discontinuation of treatment.[54] As of 2009, there have been no studies of restoration of spermatogenesis after prolonged treatment with estrogen. [52]

Benefits of Hormone Therapy: Improved Mood

Hormone treatment (transdermal estradiol + cyproterone acetate) reduced anxiety and depression scores (p < 0.001) in a cohort study of 107 trans women.[16]

Estrogen has a complex relationship to mood even in cis women.  One credible model is that estrogen fluctuations (for example, around the menstrual cycle, or around the start of menopause) cause mood disorders.  Increased vulnerability to depression in women begins with puberty and ends with menopause, though the perimenopause period is associated both with new onset of depression and increased depression symptoms. [17]  For this reason, estrogen supplementation in cis women is sometimes an effective treatment for mood disorders associated with hormone fluctuations. Estrogen has been consistently shown to be effective as a treatment for PMS, for postpartum depression, and for the milder mood problems associated with menopause, but not with severe menopausal depression or non-reproductive-related major depressive disorder.[18]

Higher doses of estrogen, on the other hand, tend to make mood problems in cis women worse. 3 mg estradiol vs. 2 mg estradiol in HRT for perimenopausal women significantly (p < 0.001) increased tension, irritability, and depressed mood, and decreased friendliness. [19] In postmenopausal women treated with 2 mg/day estrogen or placebo for three months, there was no difference in baseline mood, but the estrogen-treated group had stronger negative emotion responses to a social stress test.[20]  Chronic administration of E2 to ovariectomized female rats and mice at much higher than physiologic doses increases anxious and depressive behaviors.[21]  It’s not clear how this translates to trans women, but it may be preferable to err on the side of lower estrogen doses when possible.

The anti-androgen spironolactone is used to treat symptoms of PMS in cis women, such as irritability, depression, feeling of swelling, breast tenderness, and food craving. Unlike other anti-androgens such as cyproterone acetate or finasteride, it has not been connected with negative effects on mood or cognition.[22]

Benefits of Hormone Therapy: Reduced Gender Dysphoria

Cross-hormone therapy resulted in less body uneasiness in trans women, in a study of 125 subjects.[23]  Adolescents (mean age 17) treated vs. rejected for cross-sex hormone therapy had less gender dysphoria at follow-up in both groups, but significantly less in the treated group.  The treated group were more satisfied with their bodies.[24]

Benefits of Hormone Therapy: Higher Agreeableness

Androgen deprivation and estrogen supplementation in males (e.g. treated for prostate cancer) correlates with higher agreeableness on the Big Five personality test.[25]

Benefits of Hormone Therapy: Altered Sexual Patterns

Estrogen treatment inhibits sexual activity, spontaneous erections, and nocturnal penile tumescence.[4]   Androgen deprivation therapy in cis men (as part of treatment for prostate cancer) consistently causes reduced libido and lower frequency of early morning erections, p < 0.0001.[51] However, trans women have no higher rates of hypoactive sexual desire syndrome than cis women[47]; it may simply be that estrogen causes a more female-typical sex pattern.

Benefits of Hormone Therapy: Physical Appearance Changes

Estrogen and anti-androgens reduce hair on the trunk and limbs, but don’t completely remove it on the face; electrolysis or shaving is still usually necessary.[26]

Breast growth is usually present, with a mean hemicircumference of 18 cm after a year of hormone therapy — this is still a few centimeters less than the mean for cis women.[26]  Most trans women are dissatisfied with the final size of their breast development.[30]

Hormone therapy significantly (p < 0.01, Cohen’s d = 1) improved the “physical appearance score” for gender compatibility of transgender people, a composite made of hair, facial hair, larynx, voice, figure, height, skin, hands/feet, muscularity, chin, nose, jaw, speech, and gestures/movement.[27]

Breast growth, redistribution of body fat, and decrease in muscle mass begin at 3-6 months and peak at 2 years; decreased hair growth begins at 6-12 months and peaks at >3 years.[28]

Trans women, compared to cis men, had similar BMI but higher body fat percentage: 29% vs. 21%, p < 0.001. They also had lower grip, biceps, and quadriceps strength (p < 0.001).[29]

Non-Effects of Hormone Therapy: Cognitive Ability

A study of 35 trans men and 15 trans women at the beginning of hormone treatment, as well as 20 control (cis) men and 20 cis women, found that the trans men’s spatial rotation ability increased during 12 weeks of hormone treatment, while the trans women’s spatial rotation ability slightly declined (p < 0.01), from an average score of 101.9 to 98.5, or a 3% drop.  In this study, trans women were treated with with 100 ug/day of ethinyl estradiol and 100 ug/day of cyproterone acetate.[31]

A study of 51 trans people given hormone therapy and 29 cis controls found no effect on cognitive abilities of hormone treatment over the course of a year. Trans women were given 100 ug/day of oral ethinyl estradiol.[32]

A study of 103 trans women, treated with conjugated equine estrogens or ethinyl estradiol, and in some cases cyproterone acetate and/or medroxyprogesterone acetate, found a slight improvement in digit span after going on estrogen (6.70 on estrogen, 6.00 off estrogen), and a slight improvement in a visual recall test after going off estrogen, but mostly found no effect on a large battery of cognitive tests.[34]

The anti-androgens leuprorelin, goserelin, and cyproterone acetate, when given to men with prostate cancer, caused a drop in one or more cognitive tests in 24/50 men randomized to active treatment, compared to none of the men randomized to placebo.[33]  However, when men treated with anti-androgens were subsequently given estrogen, their memory performance improved.[50]

It seems likely that estrogen has little or no effect on cognitive abilities. Cyproterone acetate taken alone has a negative effect on cognition in cis men, and may contribute to a slight drop in spatial rotation ability in the context of hormone therapy for trans women.

Non-Effects of Hormone Therapy: All-Cause Mortality

In a retrospective study of 816 trans women and 293 trans men, all-cause mortality was not different than in the general population.[47]  In a long-term follow-up study of 2236 trans women and 876 trans men, there was no elevated mortality compared to the general population.[49] In a cohort study of 966 trans women and 365 trans men, the trans women group had 51% higher mortality than the general population, due mostly to suicide, cardiovascular disease, AIDS, and drug abuse; but the use of estrogen among trans women was not an independent predictor of mortality generally or of any cause of mortality except for cardiovascular disease. In other words, trans women are an at-risk population for problems like suicide, drug abuse, and AIDS, but hormone users are at no higher risk than non-users.[48]

Neutral Effects of Hormone Therapy: Brain Morphology

Men and women have structural brain differences. Men have larger brain volumes (and smaller ventricles) than women; they have larger hypothalamuses; and they have a higher fraction of white matter relative to gray matter.

In a study of eight trans women and six trans men, receiving estrogen and cyproterone acetate, and testosterone, respectively, as well as 9 cis male and 6 cis female controls, the trans women had significantly reduced brain and hypothalamus volume, while the trans men had significantly increased brain volume.  Brain volume decreased by a mean of 25 mL in trans women, from 1300 mL to 1275 mL, or about a 2% drop, leaving brain volume somewhere between that of cis men and cis women.[35]  Another study, of 15 trans men on testosterone and 14 trans women on estrogen and an anti-androgen, found that testosterone increased cortical thickness while estrogen and anti-androgens decreased it and increased ventricle size.[36]

While brain volume correlates with IQ,[37] and while some studies find slightly higher mean IQ in men than women (about 3.63 IQ points, extrapolated from the differences in SAT scores in a sample of 100,000)[38], the more common position among IQ researchers is that there are no significant sex differences in mean IQ.[39]  It’s not at all clear that hormone therapy’s effect on shrinking brain volume significantly impairs cognition.

Nonstandard Cases of Cross-Gender Hormone Use

Anti-Androgens May Not Be Necessary

Lower estrogen doses (0.625 mg conjugated estrogen daily) without cyproterone acetate, given to trans women, are sufficient to keep estrogen levels in the normal range for premenopausal women.[9]  7/10 trans women on estrogen alone, without anti-androgens, had testosterone levels drop into the normal female range.[10]  Given that anti-androgens, particularly cyproterone acetate, are responsible for many of the negative side effects of hormone therapy, taking estrogen alone may be a lower-risk approach to hormone therapy.

Risks of Anti-Androgens Without Estrogen: Depression and Cognitive Impairment

Men being treated for prostate cancer are regularly given anti-androgens to suppress the tumor. These men experience significantly elevated rates of anxiety and depression. (This is in contrast to trans women given anti-androgens along with estrogen, who generally experience significant psychological benefit.)

Chemical castration in men significantly reduces estrogen and testosterone levels, and causes significant increases in depression and anxiety scores (though generally subclinical.)[11]  Compared to controls, prostate cancer patients treated with anti-androgens had significant drops in spatial reasoning and executive function, more depressed mood and irritability, less energy and vigor.[12]

The anti-androgen finasteride, given to men as a treatment for hair loss, produced depressive symptoms in 64% of users and 0% of controls in responses to an internet survey (though there may be significant response bias in who chooses to take the survey); finasteride users reported sexual dysfunction, problems with attention and memory, anxiety, depression, and suicidality.[13]  An Iranian prospective study on finasteride found that it increased scores on the Beck depression inventory (p < 0.001) and HADS depression scores (p = 0.005)[14]  A meta-analysis of randomized trials found that finasteride increased the rate of erectile dysfunction, with a relative risk of 2.22 compared to placebo.[55]

Cyproterone acetate in men treated for prostate cancer is associated with declines (compared to placebo) in attention and memory.[15]

Tamoxifen

Tamoxifen is an selective estrogen-receptor modulator; its primary use is as a breast cancer drug, but it also prevents gynecomastia related to estrogen or anti-androgen use.[40]  It might in principle be possible that if one combines tamoxifen with estrogen, one can get some of estrogen’s feminizing effects without growing breasts, but I couldn’t find any case studies of this being done successfully.

Tamoxifen taken alone does not have feminizing effects on men.  It increases both serum estrogen and testosterone levels in men, and increases sperm count.[41]

Female Hormone Use in Men

Male cross-dressers do sometimes use female hormones, and in past decades the social concept of “transgender” was less sharp than it is today. In early-1990’s radical contexts, “transgender” was considered an umbrella term that would include transvestites, drag queens, feminine gay men, butch lesbians, and other gender-nonconforming people who would not usually be considered “trans” today.[43]

In a 1992 sample of 1032 male cross-dressers, 43% said they “would like to use” hormones and 9% had used or were using hormones; in a 1972 sample of of 504 male cross-dressers, 50% said they “would like to use” hormones and 9% had used or were using hormones. However, the majority of these people viewed themselves as “a man with a feminine side” rather than “a woman trapped in a man’s body,” and did not plan to live full-time as women.[42]

From a biological standpoint, there’s no strong reason to believe that hormones would have different effects depending on whether they’re taken by a person who identifies as trans or not.  Men given estrogen for medical reasons (coronary heart disease) had similar side effects as trans women do, including breast tenderness and growth, testicular shrinkage, sexual dysfunction, and depression upon discontinuing estrogen,[44] but there was no evidence of psychological disturbance as a result of taking estrogen.[45]

 

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